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KEY TERMS LEARNING OBJECTIVES achylia On completion of this chapter, you should be able to: adenoids 1. Discuss ways the infant and child’s respiratory system differs from the circumoral adult’s system. coryza 2. Name the most common complication of acute nasopharyngitis. croup 3. Discuss nursing care of the child with allergic rhinitis. dysphagia 4. Discuss nursing care of the child with tonsillitis and adenoiditis. emetic hypochylia 5. Explain the most common complication of a tonsillectomy and list the metered-dose inhaler signs requiring observation. nebulizer 6. Compare the croup syndrome disorders including: (a) spasmodic laryngitis, stridor (b) acute laryngotracheobronchitis, and (c) epiglottitis. teratogenicity 7. Discuss the symptoms, diagnosis, and treatment of acute bronchiolitis/ tonsils respiratory syncytial virus (RSV) infection. wheezing 8. Describe asthma including (a) factors that can trigger an asthma attack, (b) the physiologic response that occurs in the respiratory tract during an asthma attack, (c) treatment, and (d) nursing care. 9. Explain the diagnosis of pneumonia including the treatment and nursing care. 10. Identify the basic defect and organs affected by cystic fibrosis, along with diagnostic procedures. 11. Name the most common type of complication in cystic fibrosis and describe the dietary and pulmonary treatments of the disorder. 12. Discuss how tuberculosis is detected and treated.

RESPIRATORY disorders in infants and children are lungs. These structures are involved in the exchange of common. They range from mild to serious, even life oxygen and carbon dioxide and the distribution of the threatening. They can be acute or chronic in nature. oxygen to the body cells. Tiny, thin-walled sacs called Sometimes these problems require hospitalization, which alveoli are responsible for distributing air into the interrupts development of the child–family relationship bloodstream. It is and the child’s patterns of sleeping, eating, and stimula- also through the alve- This is critical to tion. Although the illness might be acute, if recovery is oli that carbon diox- remember. rapid and the hospitalization brief, the child probably ide is removed from The diameter of the will experience few, if any, long-term effects. However, if the bloodstream and infant and child’s tra- the condition is chronic or so serious that it requires exhaled through the chea is about the size long-term care, both child and family may suffer serious respiratory system. of the child’s little fin- ger. This small diame- consequences. The structures and ter makes it extremely organs found in the important to be aware GROWTH AND DEVELOPMENT OF respiratory system that something can easily THE RESPIRATORY SYSTEM cleanse, warm, and lodge in this small pas- The respiratory system is made up of the nose, pharynx, humidify the air that sageway and obstruct the child’s airway. larynx, trachea, epiglottis, bronchi, bronchioles, and the enters the body. 775 LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 776 Aptara

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Respiratory problems occur more often and with greater severity in infants and children than in adults be- cause of their immature body defenses and small, unde- Terminal veloped anatomical structures. The respiratory tract bronchiole To Larynx and grows and changes until the child is about 12 years of pulmonary From vocal folds age. During the first 5 years, the child’s airway increases vein pulmonary artery Esophagus in length but not in diameter. Alveolar Infants and young children have larger tongues in pro- duct Trachea portion to their mouths, shorter necks, narrower airways, Left lung Alveoli and the structures are closer together. This leads to the pos- Left bronchus sibility of respiratory obstruction, especially if there is Capillaries edema, swelling, or increased mucus in This is important. Medi- the airways. The abil- Because the infant is a astinum ity to breathe through nose breather, it is Diaphragm the mouth when the essential to keep the nose is blocked is not nasal passages clear to enable the infant automatic but devel- to breath and to eat. ops as the child’s neurologic develop- ment increases. The tonsillar tissue is enlarged in the early school-age child, but the pharynx, which contains the tonsils, is still small, so the possibility of obstruction of the upper air- way is more likely. In children older than 2 years of age, the right bronchus is shorter, wider, and more vertical than the left. Infants use the di- aphragm and ab- Think about this. dominal muscles to If the child inhales a for- breathe. Beginning eign body, it is more likely to be drawn at about age 2 to 3 into the right ■ years, the child starts bronchus rather than Figure 36-1 Anatomy of the child’s respiratory tract. using the thoracic the left. muscles to breath. The change from us- Clinical Manifestations ing abdominal to us- The child older than age 3 months usually develops fever ing thoracic muscles for respiration is completed by the early in the course of the infection, often as high as age of 7 years. Because accessory muscles are used for 102F to 104F (38.9C–40C). Younger infants usually breathing, weakness of these muscles can cause respira- are afebrile. The child sneezes and becomes irritable and tory failure (Fig. 36-1). restless. The congested nasal passages can interfere with nursing, increasing the infant’s irritability. Because the ACUTE NASOPHARYNGITIS older child can mouth breathe, nasal congestion is not as (COMMON COLD) great a concern as in the infant. The child might have The common cold is one of the most common infectious vomiting or diarrhea, which might be caused by mucous conditions of childhood. The young infant is as suscep- drainage into the digestive system. tible as the older child but generally is not exposed as frequently. Diagnosis The illness is of viral origin such as rhinoviruses, This nasopharyngeal condition might appear as the first Coxsackie virus, respiratory syncytial virus (RSV), in- symptom of many childhood contagious diseases, such fluenza virus, parainfluenza virus, or adenovirus. Bac- as measles, and must be observed carefully. The common terial invasion of the tissues might cause complications cold also needs to be differentiated from allergic rhinitis. such as ear, mastoid, and lung infections. The child ap- pears to be more susceptible to complications than is an Treatment and Nursing Care adult. The infant should be protected from people who The child with an uncomplicated cold may not need any have colds because complications in the infant can be treatment in addition to rest, increased fluids and ade- serious. quate nutrition, normal saline nose drops, suction with a LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 777 Aptara

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bulb syringe, and a humidified environment. In the older preparations, such as Dimetapp and Actifed, can be child, acetaminophen or children’s ibuprofen can be ad- helpful for some patients. Hyposensitization can be im- ministered as an analgesic and antipyretic. It is best if as- plemented, particularly if antihistamines are not helpful pirin is avoided. If the nares or upper lip become irri- or are needed chronically. Be sure to teach parents the tated, cold cream or petrolatum (Vaseline) can be used. importance of avoiding allergens and administering The child needs to be comforted by holding, rocking, antihistamines to decrease symptoms. and soothing. If the symptoms persist for several days, the child must be seen by a physician to rule out com- TONSILLITIS AND ADENOIDITIS plications, such as otitis media. Tonsillitis is a common illness in childhood resulting from pharyngitis. A brief description of the location and ALLERGIC RHINITIS (HAY FEVER) functions of the tonsils and adenoids serves as an intro- Allergic rhinitis in children is most often caused by sen- duction to the discussion of their infection and medical sitization to animal dander, house dust, pollens, and and surgical treatments. molds. Pollen allergy seldom appears before 4 or 5 years A ring of lymphoid tissue encircles the pharynx, form- of age. ing a protective barrier against upper respiratory infec- tion. This ring consists of groups of lymphoid tonsils, Clinical Manifestations including the faucial, the commonly known tonsils; pha- A watery nasal discharge, postnasal drip, sneezing, and ryngeal, known as the adenoids; and lingual tonsils. allergic conjunctivitis are the usual symptoms of allergic Lymphoid tissue normally enlarges progressively in rhinitis. Continued sniffing, itching of the nose and childhood between the ages of 2 and 10 years and palate, and the “allergic salute,” in which the child shrinks during preadolescence. If the tissue itself be- pushes his or her nose upward and backward to relieve comes a site of acute or chronic infection, it may become itching and open the air passages in the nose, are com- hypertrophied and can interfere with breathing, cause mon complaints. Because of congestion in the nose, there partial deafness, or become a source of infection in itself. is backpressure to the blood circulation around the eyes, and dark circles are visible under the eyes (Fig. 36-2). Clinical Manifestations and Diagnosis Headaches are common in older children. The child with tonsillitis may have a fever of 101F (38.4C) or more; a sore throat, often with dysphagia Treatment and Nursing Care (difficulty swallowing); hypertrophied tonsils; and ery- When possible, offending allergens are avoided or re- thema of the soft palate. Exudate may be visible on the moved from the environment. Antihistamine–decongestant tonsils. The symptoms vary somewhat with the causative organism. Throat cultures are performed to diagnose tonsillitis and the causative organism. Frequently the cause of tonsillitis is viral, although beta-hemolytic streptococcal infection also may be the cause. Treatment and Nursing Care Medical treatment of tonsillitis consists of Here’s a pharmacology analgesics for pain, fact. antipyretics for fever, A standard 10-day course and an antibiotic in of antibiotics is often rec- the case of strepto- ommended for the treatment of tonsilli- coccal infection. tis. Stress the impor- Teach parents that tance of completing the a soft or liquid diet full prescription of antibi- is easier for the child otic to ensure that the to swallow, and to streptococcal infection is eliminated. encourage the child to maintain good fluid intake. A cool-mist vaporizer may be used to ease respirations. Tonsillectomies and adenoidectomies are controver- sial. One can be performed independent of the other, ■ Figure 36-2 Back pressure to blood circulation around the eyes leads to dark areas under the eyes in the child with but they are often done together. No conclusive evidence allergic rhinitis. The child pushes the nose upward in the has been found that a tonsillectomy in itself improves a “allergic salute” to relieve itching and open the airway. child’s health by reducing the number of respiratory LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 778 Aptara

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infections, increasing the appetite, or improving gen- Outcome Identification and Planning eral well-being. Currently, tonsillectomies generally are The major postoperative goals for the child include pre- not performed unless other measures are ineffective or venting aspiration; relieving pain, especially while swal- the tonsils are so hypertrophied that breathing and eat- lowing; and improving fluid intake. The major goal for ing are difficult. Tonsillectomies are not performed the family is to increase knowledge and understanding of while the tonsils are infected. The adenoids are more postdischarge care and possible complications. Design susceptible to chronic infection. An indication for ade- the plan of care with these goals in mind. noidectomy is hypertrophy of the tissue to the extent of impairing hearing or interfering with breathing. Per- Implementation forming only an adenoidectomy if the tonsil tissue ap- Preventing Aspiration Postoperatively pears to be healthy is an increasingly common practice. Tonsillectomy is postponed until after the age of 4 or 5 Immediately after a tonsillectomy, place the child in a years, except in the rare instance when it appears it is partially prone position with head turned to one side un- urgently needed. Often when a child has reached the til the child is completely awake. This position can be ac- acceptable age, the apparent need for the tonsillectomy complished by turning the child partially over and by has disappeared. flexing the knee where the child is not resting to help maintain the position. Keeping the head slightly lower than the chest helps facilitate drainage of secretions. Nursing Process for the Child Avoid placing pillows under the chest and abdomen, Having a Tonsillectomy which may hamper respiration. Encourage the child to Assessment expectorate all secretions, and place an ample supply of Much of the preoperative preparation, such as complete tissues and a waste container near him or her. Discour- blood count, bleeding and clotting time, and urinalysis, age the child from coughing. Check vital signs every 10 is done on a preadmission outpatient basis. In many fa- to 15 minutes until the child is fully awake and then cilities, the child is admitted on the day of surgery or the check every 30 minutes to 1 hour. Note the child’s pre- procedure is done in a day surgery setting. Psychological operative baseline vital signs to interpret the vital signs preparation is often accomplished through preadmission correctly. Hemorrhage is the most common complica- orientation. Acting out the forthcoming experience, par- tion of a tonsillectomy. Bleeding is most often a concern ticularly in a group, with the use of puppets, dolls, and within the first 24 hours after surgery and the fifth to play-doctor or play-nurse material helps the child de- seventh postoperative day. During the 24 hours after velop security. The amount and the timing of prepara- surgery, observe, document, and report any unusual rest- tion before admission depend on the child’s age. The lessness or anxiety, frequent swallowing, or rapid pulse child may become frightened about losing a body part. that may indicate bleeding. Vomiting dark, old blood Telling the child that the troublesome tonsils are going to may be expected, but bright, red-flecked emesis or ooz- be “fixed” is a much better choice than saying that they ing indicates fresh bleeding. Observe the pharynx with a are going to be “taken out.” Include the child and the flashlight each time vital signs are checked. Bleeding can caregiver in the admission interview. Ask about any occur when the clots dissolve between the fifth and sev- bleeding tendencies because postoperative bleeding is a enth postoperative days if new tissue is not yet present. concern. Carefully explain all procedures to the child Because the child is cared for at home by this time, give and be sensitive to the child’s apprehension. Take and the family caregivers information concerning signs and record vital signs to establish a baseline for postopera- symptoms for which to watch. tive monitoring. The temperature is an important part of the data collection to determine that the child has no up- Providing Comfort and Relieving Pain per respiratory infection. Observe the child for loose Apply an ice collar postoperatively; however, remove the teeth that could cause a problem during administration collar if the child is uncomfortable with it. Administer of anesthesia, document findings. pain medication as ordered. Liquid acetaminophen with codeine is often prescribed. Rectal or intravenous anal- Selected Nursing Diagnoses gesics may be used. Encourage the caregiver to remain at ■ Risk for Aspiration postoperatively related to the bedside to provide soothing reassurance. Crying irri- impaired swallowing and bleeding at the operative tates the raw throat and increases the child’s discomfort; site thus, it should be avoided if possible. Teach the caregiver ■ Acute Pain related to surgical procedure what may be expected in drainage and signs that should ■ Deficient Fluid Volume related to inadequate oral be reported immediately to the nursing staff. intake secondary to painful swallowing ■ Deficient Knowledge related to caregivers under- Encouraging Fluid Intake standing of postdischarge home care and signs and When the child is fully awake from surgery, give small symptoms of complications amounts of clear fluids or ice chips. Synthetic juices, LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 779 Aptara

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carbonated beverages that are “flat,” and frozen juice CROUP SYNDROMES popsicles are good choices. Croup is not a disease, but a group of disorders typically Avoid irritating liquids, such as orange juice and lemon- involving a barking cough, hoarseness, and inspiratory ade. Milk and ice cream products tend to cling to the sur- stridor (shrill, harsh respiratory sound). The disorders gical site and make swallowing more difficult; thus, they are named for the respiratory structures involved. Acute are poor choices, de- laryngotracheobronchitis, for instance, affects the lar- spite the old tradition Here’s a helpful hint. ynx, trachea, and major bronchi. of offering ice cream After a tonsillectomy, offer after a tonsillectomy. the child liquids that are SPASMODIC LARYNGITIS Continue administra- not red in color to tion of intravenous eliminate confusion Spasmodic laryngitis occurs in children between ages with bloody dis- 1 and 3 years. The cause is undetermined; it may be of fluid and record in- charge. take and output until infectious or allergic origin, but certain children seem to adequate oral intake develop severe laryngospasm with little, if any, apparent is established. cause. Providing Family Teaching Clinical Manifestations and Diagnosis The child typically is discharged on the day of or the day The attack may be preceded by coryza (runny nose) and after surgery if no complications are present. Instruct the hoarseness or by no apparent signs of respiratory irreg- caregiver to keep the child relatively quiet for a few days ularity during the evening. The child awakens after a few after discharge. Recommend giving soft foods and non- hours of sleep with a bark-like cough, increasing respi- irritating liquids for the first few days. Teach family ratory difficulty, and stridor. The child becomes anxious, members that if at any time after the surgery they note restless, and markedly hoarse. A low-grade fever and any signs of hemorrhage (bright red bleeding, frequent mild upper respiratory infection may be present. swallowing, restlessness), they should notify the care This condition is not serious but is frightening both to provider. Provide written instructions and telephone the child and to the family. The episode subsides after a numbers before discharge. Advise the caregivers that a few hours; little evidence remains the next day when an mild earache may be expected about the third day. anxious caregiver takes the child to the physician. At- tacks frequently occur 2 or 3 nights in succession. Evaluation: Goals and Expected Outcomes Goal: The child’s airway will remain patent after surgery. Treatment and Nursing Care Expected Outcomes: The child Humidified air is helpful in reducing laryngospasm. Hu- ■ shows signs of an open and clear airway. midifiers may be used in the child’s bedroom to provide ■ expectorates saliva and drainage with no aspiration. high humidity. Cool humidifiers are recommended, but Goal: The child will show signs of being comfortable. vaporizers also may be used. If a vaporizer is used, cau- Expected Outcomes: The child tion must be taken to place it out of the child’s reach to ■ rests quietly and does not cry. protect the child from being burned. Cool-mist humidi- ■ exhibits pulse rate that is regular and normal for fiers provide safe humidity. Humidifiers and vaporizers their age. must be cleaned regularly to prevent the growth of unde- ■ states that pain is lessened. sirable organisms. Sometimes the spasm is relieved by ex- posure to cold air—when, for instance, the child is taken Goal: The child’s fluid intake will be adequate for out into the night to their age. go to the emergency Expected Outcomes: The child’s department or to see Good news. ■ skin turgor is good. the care provider. Although frightening to ■ mucous membranes are moist. The physician may the child and family, ■ hourly urinary output is at least 20 to 30 mL. spasmodic laryngitis is prescribe an emetic not serious and can ■ parenteral fluids are maintained until oral fluid (an agent that causes often be lessened intake is adequate. vomiting) in a dosage quickly by taking the Goal: Family caregivers will verbalize an understand- less than that needed child into the bathroom, ing of postdischarge care. to produce vomiting; shutting the door, and Expected Outcomes: Family caregivers turning on the hot water this usually gives re- tap. This fills the room with ■ give appropriate responses when questioned about lief by helping to re- steam or humidified air and care at home. duce spasms of the relieves the child’s symptoms. ■ verbalize signs and symptoms of complications and larynx. ask appropriate questions for clarification. It is important to explain which symptoms can be treated at home (hoarseness, croupy cough, and inspiratory LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 780 Aptara

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stridor) and which symptoms might indicate a more se- rious condition in which the child needs to be seen by the care provider (continuous stridor, use of accessory muscles, labored breathing, lower-rib retractions, rest- lessness, pallor, and rapid respirations). The family must be aware that recurrence of these conditions may occur. ACUTE LARYNGOTRACHEOBRONCHITIS Laryngeal infections are common in small children, and they often involve tracheobronchial areas as well. Acute laryngotracheobronchitis (bacterial tracheitis or laryn- gotracheobronchitis) may progress rapidly and become a serious problem within a matter of hours. The toddler is the most frequently affected age group. This condition is usually of viral origin, but bacterial invasion, usually staphylococcal, follows the original infection. It gener- ally occurs after an upper respiratory infection with fairly mild rhinitis and pharyngitis.

Clinical Manifestations and Diagnosis ■ Figure 36-3 The “tripod” position of the child with The child develops hoarseness and a barking cough with epiglottitis. a fever that may reach 104F to 105F (40C–40.6C). As the disease progresses, marked laryngeal edema oc- curs, and the child’s breathing becomes difficult, the pulse is rapid, and cyanosis may appear. Heart failure larynx). Commonly caused by Haemophilus influenzae and acute respiratory embarrassment can result. type B, epiglottitis most often affects children ages 2 to 7 years. The epiglottis becomes inflamed and swollen Treatment and Nursing Care with edema. The edema decreases the ability of the The major goal of treatment for acute laryngotracheo- epiglottis to move freely, which results in blockage of the bronchitis is to maintain an airway and adequate air ex- airway and creates an emergency. change. Antimicrobial therapy is ordered. The child is placed in a supersaturated atmosphere, such as a Clinical Manifestations and Diagnosis croupette or some other kind of mist tent, that also can The child may have been well or may have had a mild include the administration of oxygen. To achieve bron- upper respiratory infection before the development of a chodilation, racemic or nebulized epinephrine may be sore throat, dysphagia (difficulty swallowing), and a administered, usually by a respiratory therapist. Nebu- high fever of 102.2F to 104F (39C–40C). The dys- lization is usually administered every 3 or 4 hours. Neb- phagia may cause drooling. A tongue blade should never ulization often produces rapid relief because it causes be used to initiate a gag reflex because complete ob- vasoconstriction. However, the child requires careful ob- struction may occur. The child is very anxious and servation for the reappearance of symptoms. prefers to breathe by sitting up and leaning forward with If necessary, intubation with a nasotracheal tube may the mouth open and the tongue out. This is called the be performed for a child with severe distress unrelieved “tripod” position (Fig. 36-3). Immediate emergency at- by other measures. Tracheostomies, once performed fre- tention is necessary. quently, are rarely performed today; intubation is pre- ferred. Antibiotics are administered parenterally initially and continued after the temperature has normalized. Treatment and Nursing Care Close and careful observation of the child is impor- The child may need endotracheal intubation or a tra- tant. Observation includes checking the pulse, respira- cheostomy if the epiglottis is so swollen that intubation tions, and color; listening for hoarseness and stridor; and cannot be performed. Moist air is necessary to help re- noting any restlessness that may indicate an impending duce the inflammation of the epiglottis. Pulse oximetry is respiratory crisis. Pulse oximetry is used to determine the required to monitor oxygen requirements. Antibiotics degree of hypoxia. are administered intravenously. After 24 to 48 hours of antibiotic therapy, the child may be extubated. Antibi- EPIGLOTTITIS otic therapy usually is continued for 10 days. This con- Epiglottitis is acute inflammation of the epiglottis (the dition is not common, and it is extremely frightening for cartilaginous flap that protects the opening of the the child and the family. LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 781 Aptara

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chemotherapy. Rib- ACUTE BRONCHIOLITIS/RESPIRATORY Warning. SYNCYTIAL VIRUS INFECTION avirin is classified as Women who might be Acute bronchiolitis (acute interstitial pneumonia) is most a category X drug, pregnant should stay out common during the first 6 months of life and is rarely signifying a high risk of the room where seen after the age of 2 years. Most cases occur in infants for teratogenicity (ca- ribavirin is being who have been in contact with older children or adults using damage to a administered. with upper respiratory viral infections. It usually occurs fetus). Health care in the winter and early spring. personnel and others Acute bronchiolitis is caused by a viral infection. The may inhale the mist causative agent in more than 50% of cases has been that escapes into the shown to be RSV. Other viruses associated with the dis- room, so care must be taken when the drug is administered. ease are parainfluenza virus, adenoviruses, and other For children who are at high risk for getting RSV and viruses not always identified. having serious complications, there are some new drugs The bronchi and bronchioles become plugged with available that may be given to prevent RSV. These drugs thick, viscid mucus, causing air to be trapped in the are administered only in specific cases and are given in- lungs. The child can breathe air in but has difficulty ex- travenously or intramuscularly. pelling it. This hinders the exchange of gases and cyanosis appears. Clinical Manifestations Test Yourself The onset of dyspnea is abrupt, sometimes preceded by ✔ What is the most common complication after a ton- a cough or nasal discharge. Manifestations include a dry sillectomy? What two time periods is bleeding a con- and persistent cough, extremely shallow respirations, air cern after a tonsillectomy? Explain the reasons these hunger, and often marked cyanosis. Suprasternal and time periods are a concern for bleeding. subcostal retractions are present. The chest becomes bar- ✔ What is a fast and effective way to reduce laryn- rel-shaped from the trapped air. Respirations are 60 to gospasm for the child with croup? 80 breaths per minute. ✔ What is a complication often seen in the infant with Fever is not extreme, seldom higher than 101 F to a respiratory infection? 102F (38.3C–38.9C). Dehydration may become a se- ✔ rious factor if competent care is not given. The infant ap- What is the causative agent in many cases of bron- pears apprehensive, irritable, and restless. chiolitis? Diagnosis Diagnosis is made from clinical findings and can be con- firmed by laboratory testing (enzyme-linked immunosor- ASTHMA bent assay [ELISA]) of the mucus obtained by direct Asthma is a spasm of the bronchial tubes caused by hy- nasal aspiration or nasopharyngeal washing. persensitivity of the airways in the bronchial system and inflammation that leads to mucosal edema and mucous Treatment and Nursing Care hypersecretion. Asthma is also sometimes referred to as The child is usually hospitalized and treated with high reactive airway disease. This reversible obstructive air- humidity by mist tent (see Chapter 30, Fig. 30-6), rest, way disease affects millions of people in the United and increased fluids. Oxygen may be administered in ad- States, including 5% to 10% of all children in the United dition to the mist tent. Monitoring of oxygenation may States. be done by means of capillary blood gases or pulse Asthma attacks are often triggered by a hypersensitive oximetry. Antibiotics are not prescribed because the response to allergens. In young children, asthma may be causative organism is a virus. Intravenous fluids often a response to certain foods. Asthma is often triggered by are administered to ensure an adequate intake and to exercise, exposure to cold weather, irritants such as permit the infant to rest. The hospitalized child is placed wood-burning stoves, cigarette smoke, dust, and pet on contact transmission precautions to prevent the dander and foods such as chocolate, milk, eggs, nuts, spread of infection. and grains. Infections, such as bronchitis and upper res- Ribavirin (Virazole) is an antiviral drug that may be piratory infection, can provoke asthma attacks. In chil- used to treat certain children with RSV. It is administered dren with asthmatic tendencies, emotional stress or anx- as an inhalant by hood, mask, or tent. The American iety can trigger an attack. Some children with asthma Academy of Pediatrics states that the use of ribavirin must may have no evidence of an immunologic cause for the be limited to children at high risk for severe or complicated symptoms. RSV such as children with chronic lung disease, premature Asthma can be either intermittent, with extended peri- infants, transplant recipients, and children receiving ods when the child has no symptoms and does not need LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 782 Aptara

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■ Figure 36-4 Note airway Normal airway Airway with inflammation Airway with inflammation, edema, mucus production, and bronchospasm, bronchospasm occurring with and mucus production asthma.

medication, or chronic, with the need for frequent or diagnosis of asthma is made when the obstruction in the continuous therapy. Chronic asthma affects the child’s airways is reversed with bronchodilators. school performance and general activities and may con- tribute to poor self-confidence and dependency. Asthma Treatment accounts for one third of the missed school days in the Children and their families must be taught to recognize United States (Eggleston, 2006). the symptoms that lead to an acute attack so they can be Spasms of the smooth muscles cause the lumina of treated as early as possible. These symptoms include respi- the bronchi and bronchioles to narrow. Edema of the ratory retractions and wheezing and an increased amount mucous membranes lining these bronchial branches of coughing at night, in the early morning, or with activ- and increased production of thick mucus within them ity. Use of a peak flow meter is an objective way to meas- combine with the spasm to cause respiratory obstruc- ure airway obstruction, and children as young as 4 or tion (Fig. 36-4). 5 years of age can be taught to use one (see Family Teach- ing Tips: How to Use a Peak Flow Meter and Fig. 36-5). Clinical Manifestations A peak flow diary The onset of an attack can be very abrupt or can should be maintained Did you know? progress over several days, as evidenced by a dry hack- and also can include Prevention is the most ing cough, wheezing (the sound of expired air being symptoms, exacerba- important aspect in the pushed through obstructed bronchioles), and difficulty tions, actions taken, treatment of asthma. breathing. Asthma attacks often occur at night and and outcomes. Fami- awaken the child from sleep. The child must sit up and lies must make every is totally preoccupied with efforts to breathe. Attacks effort to eliminate might last for only a short time, or might continue for any possible allergens several days. Thick, tenacious mucus might be from the home. coughed up or vomited after a coughing episode. In some asthmatic patients, coughing is the major symp- tom, and wheezing occurs rarely if at all. Many chil- dren no longer have symptoms after puberty, but this is not predictable. Other allergies may develop in adulthood. Diagnosis The history and physical examination are of primary im- portance in diagnosing asthma. When observing the child’s breathing, dyspnea and labored breathing may be noted, especially on expiration. When listening to the child’s lung sounds (auscultation), the examiner hears wheezing, which is often generalized over all lung fields. Mucus production may be profuse. Pulmonary function tests are valuable diagnostic tools and indicate the amount of obstruction in the bronchial airways, espe- ■ Figure 36-5 The child with asthma uses a peak flow me- cially in the smallest airways of the lungs. A definitive ter and keeps track of readings on a daily basis. LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 783 Aptara

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Family Teaching Tips HOW TO USE A PEAK FLOW METER

INTRODUCTION STEPS TO ACCURATE MEASUREMENTS Your child cannot feel early changes in the airway. By 1. Remove gum or food from the mouth. the time the child feels tightness in the chest or starts to 2. Move the pointer on the meter to zero. wheeze, he or she is already far into an asthma episode. 3. Stand up and hold the meter horizontally with fin- The most reliable early sign of an asthma episode is a gers away from the vent holes and marker. drop in the child’s peak expiratory flow rate, or the abil- 4. With mouth wide open, slowly breathe in as much ity to breathe out quickly, which can be measured by a air as possible. peak flow meter. Almost every asthmatic child over the 5. Put the mouthpiece on the tongue and place lips age of 4 years can and should learn to use a peak flow around it. meter (Figs. A and B.) 6. Blow out as hard and fast as you can. Give a short, sharp blast, not a slow blow. The meter measures the fastest puff, not the longest. 7. Repeat steps 1–6 three times. Wait at least 10 sec- onds between puffs. Move the pointer to zero after each puff. 8. Record the best reading.

GUIDELINES FOR TREATMENT Each child has a unique pattern of asthma episodes. Most episodes begin gradually, and a drop in peak flow can alert you to start medications before the actu- al symptoms appear. This early treatment can prevent a flare-up from getting out of hand. One way to look at peak flow scores is to match the scores with three colors:

A Green Yellow Red 80%–100% 50%–80% Below 50% personal best personal best personal best No symptoms Mild to moder- Serious ate symptoms distress Full breathing Diminished Pulmonary reserve reserve function is significantly impaired Mild trigger A minor trigger Any trigger may not cause produces may lead to symptoms noticeable severe symptoms distress Continue Augment present Contact care current treatment provider management regimen B

Remember, treatment should be adjusted to fit the individual’s needs. Your care provider will develop a home management plan with you. When in doubt, consult your care provider.

The goals of asthma treatment include preventing on the frequency and severity of symptoms and exacer- symptoms, maintaining near-normal lung function and bations, a stepwise approach to the treatment of activity levels, preventing recurring exacerbations and asthma is used to manage the disease. The steps are hospitalizations, and providing the best medication used to determine combinations of medications to be treatment with the fewest adverse effects. Depending used (Table 36-1). LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 784 Aptara

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Theophylline preparations have long been used in Table 36-1 ❚ STEPWISE APPROACH TO the treatment of asthma. The drug is available in short- TREATING ASTHMA acting and long-acting forms. The short-acting forms are given about every 6 hours. Because they enter the Steps Symptoms bloodstream quickly, they are most effective when used Step One only as needed for intermittent episodes of asthma. Mild intermittent Symptoms occur 2 times a week Long-acting preparations of theophylline are given No symptoms between every 8 to 12 hours. Some of these preparations come exacerbations in sustained-release forms. These are helpful in pa- Exacerbations brief tients who continually need medication because these Nighttime symptoms 2 times a month drugs sustain more consistent theophylline levels in the blood than do short-acting forms. Patients hospitalized Step Two Mild persistent Symptoms occur 2 times a week for status asthmaticus may receive theophylline intra- but 1 time a day venously. Exacerbations may affect activity Nighttime symptoms 2 times Corticosteroids a month Corticosteroids are anti-inflammatory drugs used to Step Three control severe or chronic cases of asthma. Steroids may Moderate persistent Daily symptoms Daily use of inhaled short-acting be given in inhaled form to decrease the systemic effects beta-2 agonist that accompany oral steroid administration. Exacerbations affect activity Exacerbations 2 times a week, Leukotriene Inhibitors may last days Nighttime symptoms 1 time Leukotriene inhibitors are given by mouth along with a week other asthma medications for long-term control and pre- Step Four vention of mild, persistent asthma. Leukotrienes are Severe persistent Continual symptoms bronchoconstrictive substances that are released in the Limited physical activity body during the inflammatory process. These drugs in- Frequent exacerbations hibit leukotriene production, which helps with bron- Frequent nighttime symptoms chodilation and decreases airway edema.

Mast Cell Stabilizers Medications used to treat asthma are divided into two Mast cell stabilizers help to stabilize the cell membrane categories: quick-relief medications for immediate treat- by preventing mast cells from releasing the chemical me- ment of symptoms and exacerbations and long-term con- diators that cause bronchospasm and mucous membrane trol medications to achieve and maintain control of the inflammation. They are used to help decrease wheezing symptoms. The classifications of drugs used to treat asthma and exercise-induced asthma attacks. These are nons- include bronchodilators (sympathomimetics and xanthine teroidal anti-inflammatory drugs and have relatively few derivatives) and other antiasthmatic drugs (corticosteroids, side effects. A bronchodilator often is given to open up leukotriene inhibitors, and mast cell stabilizers). Table 36-2 the airways just before the mast cell stabilizer is used. lists some of the medications used to treat asthma. Many of Children dislike the taste of the medication, but receiv- these drugs can be given either by a nebulizer (tube at- ing sips of water after the administration minimizes the tached to a wall unit or cylinder that delivers moist air via distaste. a face mask) or a metered-dose inhaler ([MDI]; a hand-held plastic device that delivers a premeasured dose). The MDI Chest Physiotherapy may have a spacer unit attached that makes it easier for the Because asthma has multiple causes, treatment and con- young child to use (Fig. 36-6). tinued management of the disease require more than med- ication. Chest phys- Bronchodilators iotherapy includes Check out this tip. Bronchodilators are used for quick relief of acute exacer- breathing exercises, physical training, and For the asthmatic child, if bations of asthma symptoms. They are short acting and exercises can be taught available in pill, liquid, or inhalant form. These drugs are inhalation therapy. as part of play activi- administered every 6 to 8 hours or every 4 to 6 hours by Studies have shown ties, children are inhalation if breathing difficulty continues. In severe at- that breathing exer- more likely to find tacks, epinephrine by subcutaneous injection often affords cises to improve res- them fun and to prac- tice them more often. quick relief of symptoms. Some bronchodilators, such as piratory function and salmeterol (Serevent), are used in long-term control. to control asthma LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 785 Aptara

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Table 36-2 ❚ MEDICATIONS USED IN THE TREATMENT OF ASTHMA

Generic Name Trade Name Dose Form Uses Adverse Reactions/Side Effects

Bronchodilators Sympathomimetics (Beta-2-receptor Agonists) albuterol sulfate Proventil, Ventolin MDI Quick relief Restlessness, anxiety, fear, PO palpitations, insomnia, tremors Nebulizer metaproterenol Alupent, Metaprel MDI Quick relief Tremors, anxiety, insomnia, hydrochloride PO Short-term dizziness, tachycardia Nebulizer control terbutaline sulfate Brethine MDI MDI—Quick Tremors, anxiety, insomnia, PO relief dizziness, tachycardia PO—Long-term control salmeterol Serevent MDI Long-term Headache, tremors, tachycardia control Xanthine Derivative Theophylline Slo-Phyllin, PO Long-term Nausea, vomiting, headache, Elixophyllin Timed- control nervousness, irritability, Theo-Dur release insomnia Antiasthma Drugs Corticosteroids beclomethasone Beclovent MDI Long-term Throat irritation, cough, nausea, control dizziness triamcinolone Azamacort MDI Long-term Throat irritation, cough, nausea, control dizziness Leukotriene Inhibitors Montelukast Singulair PO Long-term Headache, nausea, abdominal control pain, diarrhea Mast Cell Stabilizers Cromolyn Intal Intranasal Long-term Nasal irritation, unpleasant taste, nebulizer control headache, nausea, dry throat

MDI metered-dose inhaler

attacks can be an important adjunct to using medica- Nursing Process for the Child With Asthma tions for treatment. These exercises teach children how Assessment to help control their own symptoms and thereby build Obtain information from the caregiver about the asthma self-confidence, which is sometimes lacking in asthmatic history, the medications the child takes, and the medications children.

AB ■ Figure 36-6 (A) Girl using a nebulizer with a mask. (B) Boy using a metered-dose in- haler with spacer. LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 786 Aptara

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taken within the last 24 hours. Ask whether the child has Monitoring and Improving Fluid Intake vomited because vomiting would prevent absorption of During an acute attack, the child may lose a great quan- oral medications. Ask about any history of respiratory tity of fluid through the respiratory tract and may have infections; possible allergens in the household such as a poor oral intake because of coughing and vomiting. pets; type of furniture and toys; if there is a damp base- Theophylline administration also has a diuretic effect, ment (which could contain mold spores); and a history which compounds the problem. Monitor intake and out- of breathing problems after exercise. put. Encourage oral fluids that the child likes. Intra- In the physical exam, include vital signs, observation venous (IV) fluids are administered as ordered. IV fluid for diaphoresis and cyanosis, position, type of breathing, intake is monitored, and all precautions for parenteral alertness, chest movement, intercostal retractions, and administration are followed. Note the skin turgor and breath sounds. Note any wheezing. observe the mucous membranes at least every 8 hours. If the child is old enough and alert enough to cooper- Weigh the child daily to help determine fluid losses. ate, involve him or her in gathering the history, and en- courage the child to add information. Ask questions that Promoting Energy Conservation can be answered “yes” or “no” to minimize tiring the The child might become extremely tired from the exer- distressed child. tion of trying to breathe. Activities and patient care should be spaced to provide maximum periods of unin- terrupted rest. Provide quiet activities when the child Selected Nursing Diagnoses needs diversion. Keep visitors to a minimum, and main- ■ Ineffective Airway Clearance related to bron- tain a quiet environment. chospasm and increased pulmonary secretions ■ Risk for Deficient Fluid Volume related to water loss Reducing Child and Parent Anxiety from tachypnea and diaphoresis and reduced oral The sudden onset of an asthma attack can be frightening intake to the child and the family caregivers. Respond quickly ■ Fatigue related to dyspnea when the child has an attack. Reassure the child and the ■ Anxiety related to sudden attacks of breathlessness family during an episode of dyspnea. ■ Deficient Knowledge of the caregiver related to dis- ease process, treatment, home care, and control of disease

Outcome Identification and Planning A Personal Glimpse The initial major goals for the child include maintaining a clear airway and an adequate fluid intake and relieving The first time I put Bobbie in the hospital it was very scary. I knew the nurses, but I was still afraid for him. I felt like fatigue and anxiety. The family’s goals include learning someone was punishing me. I couldn’t leave him for a how to manage the child’s life with asthma. Base the minute. I was afraid he wouldn’t be alive when I came back. nursing plan of care on these goals. I was also afraid he would be frightened. He was so small, he needed me to protect him, but I couldn’t help him. We were in the hospital every couple of weeks. He would get Implementation better then have another attack. It got to the point where I Monitoring Respiratory Function would call the doctor and say that Bobbie was having an- Continuously monitor the child while he or she is in other attack and they would just send us to admitting. Af- acute distress from an asthma attack using pulse oxime- ter a few times, I got used to caring for him in the hospital. The nurses taught me how to keep his tent humidified and try and an electronic monitor. If this equipment is un- I could just take care of it myself. Finally I was able to go available, take the child’s respirations every 15 minutes back to work during the day and care for him on my breaks during an acute attack and every 1 or 2 hours after the and time off. It was very difficult each and every time, but crisis is over. Listening to lung sounds should be done to we adjusted to hospital life. Although I was afraid for him, I further monitor the respiratory function. Observe for knew he was a fighter and I had to be too. I feel this expe- nasal flaring and chest retractions; observe the skin for rience made him a stronger person. He is now 8 years old color and diaphoresis. and has had no severe attacks since he was about 2 years Elevate the child’s head. An older child may be more old. He has had a few mild attacks, but it doesn’t affect him comfortable resting forward on a pillow placed on an or myself. over-bed table. Monitor the child for response to med- Tracee ications and their side effects such as restlessness, gas- Learning Opportunity: Give specific examples of what trointestinal upset, and seizures. Use humidified oxy- the nurse could do to support this mother and to help de- gen and suction as needed during periods of acute crease the fear she had when her child was hospitalized. distress. LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 787 Aptara

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Teach the child Nursing judgment is and the caregiver the Family Teaching Tips in order. symptoms of an im- The asthmatic child’s fear HOW TO USE A pending attack and of attacks can be METERED-DOSE INHALER the immediate re- increased by the care- sponse needed to giver’s behavior. ■ When ready to use, shake the inhaler well with the decrease the threat cap still on. The child should stand, if possible. of an attack. This ■ Remove the cap. knowledge will help ■ Hold the inhaler with the mouthpiece down, them to cope with facing the child. impending attacks ■ Be sure the child’s mouth is empty. and plan how to handle the attacks. When they are pre- ■ Hold the mouthpiece about 1 to 1.5 in from the pared with information, the child and family may be lips.* less fearful. Give the child examples of sports figures, ■ Breathe out normally. Open mouth wide and entertainers, actors and actresses, and political leaders begin to breathe in. who have or have had asthma, for example, Olympic ■ Press top of medication canister firmly while track and field athlete Jackie Joyner Kersee and Presi- inhaling deeply. Hold breath as long as possible dent John F. Kennedy. Others include Jerome Bettis, (at least 10 seconds—teach child to count slowly professional football player; Amy Van Dyken, American to 10). swimming champion; Nancy Hogshead, Olympic gold ■ Breathe out slowly through nose or pursed lips. medalist in swimming; Dennis Rodman, NBA basket- ■ Relax 2 to 5 minutes repeat as directed by physi- ball player; and Diane Keaton, actress. cian.

Providing Family Teaching *The mouthpiece can also be put between the lips, with the lips Child and family caregiver teaching is of primary im- forming an airtight seal, or a spacer can be attached to the portance in the care of asthmatic children. Family care- inhaler and the mouthpiece held between the lips. givers might overprotect the child because of the fear that an attack will occur when the child is with a babysitter, at school, or anywhere away from the care- giver. Asthma attacks can be prevented or decreased by be permitted to bring medications to school and keep prompt and adequate intervention. Teach the caregiver them so they can be used when needed. and child, within the scope of the child’s ability to un- Provide information on support groups available in derstand, about the disease process, recognition of the area. The American Lung Association has many ma- symptoms of an impending attack, environmental con- terials available to families and can provide information trol, infection avoidance, exercise, drug therapy, and about support groups, camps, and workshops (Web site: chest physiotherapy. www. lungusa.org). The Asthma and Allergy Founda- Teach the caregiver and the child how to use metered- tion of America (Web site: www.aafa.org) and the Na- dose inhaler medications and have them demonstrate tional Heart, Lung, and Blood Institute (Web site: correct usage (see Family Teaching Tips: How to Use a www.nhlbi.nih.gov) are also resources. Metered-Dose Inhaler). Give instructions on home use of a peak flow meter. Urge them to maintain a diary to Evaluation: Goals and Expected Outcomes record the peak flow as well as asthma symptoms, onset Goal: The child’s airway will remain open. of attacks, action taken, and results. Include instruc- Expected Outcomes: The child’s tions about administering premedication before the ■ breath sounds are clear with no wheezing, retrac- child is exposed to situations in which an attack may tions, or nasal flaring. occur. ■ skin color is good. Inform caregivers of allergens that may be in the Goal: The child’s fluid intake will be adequate. child’s environment and encourage them to eliminate or Expected Outcomes: The child’s control the allergens as needed. Stress the importance of ■ hourly urine output is 30 to 40 mL. quick response when the child has a respiratory infec- ■ mucous membranes are moist. tion. Give instructions for exercise and chest physio- ■ skin turgor is good. therapy. ■ weight remains stable. Stress to the caregivers the importance of informing the child’s classroom teacher, physical education teacher, Goal: The child will have increased energy levels. school nurse, babysitter, and others who are responsible Expected Outcomes: The child for the child about the child’s condition. With a physi- ■ participates in age-appropriate activities. cian’s order, including directions for use, the child should ■ rests between activities. LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 788 Aptara

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Goal: The child’s and caregivers’ anxiety and fear re- conjugate vaccine (HIB) is currently recommended, be- lated to impending attacks will be minimized. ginning at 2 months of age. Expected Outcomes: The child and the caregiver ■ list symptoms of an impending attack. Clinical Manifestations ■ describe appropriate responses. The onset of the pneumonic process is usually abrupt, ■ display confidence in their ability to handle an following a mild upper respiratory illness. Temperature attack. increases rapidly to 103F to 105F (39.4C–40.6C). Goal: The child and the caregiver will gain Respiratory distress is marked with obvious air hunger, knowledge of how to live with asthma. flaring of the nostrils, circumoral (around the mouth) Expected Outcomes: The child and the caregiver cyanosis, and chest retractions. Tachycardia and tachyp- nea are present, with a pulse rate frequently as high as ■ verbalize an understanding of the disease process, 140 to 180 beats per minute and respirations as high as treatment, and control. 80 breaths per minute. ■ interact with health care personnel and ask and Generalized convulsions may occur during the period answer relevant questions. of high fever. Cough may not be noticeable at the onset ■ obtain information and makes contact with support but may appear later. Abdominal distention caused by groups. swallowed air or paralytic ileus commonly occurs. Test Yourself Diagnosis Diagnosis is based on clinical symptoms, chest radi- ✔ What is the most important aspect in the treatment ograph, and culture of the organism from secretions. of asthma? The white blood cell count may be elevated. The anti- ✔ What are the two categories of medications used in streptolysin titer (ASO titer) is usually elevated in chil- the treatment of asthma? dren with staphylococcal pneumonia. ✔ What are the routes of administration for many of the medications used to treat asthma? Treatment ✔ Why is chest physiotherapy used in the treatment of The use of anti-infectives early in the disease gives a asthma? prompt and favorable response. Penicillin or ampicillin has proved to be the most effective treatment and is gen- erally used unless the child has a penicillin allergy. Cephalosporin anti-infectives are also used. Oxygen BACTERIAL PNEUMONIA started early in the disease process is important. In some Pneumococcal pneumonia is the most common form of instances, a croupette or mist tent is used. Some consider bacterial pneumonia in infants and children. Its inci- the use of mist tents without constant observation un- dence has decreased during the last several years. This safe. Children have become cyanotic in mist tents, with disease occurs mainly during the late winter and early subsequent arrest, because of the difficulty of seeing the spring, principally in children younger than 4 years of child; therefore, a mask or hood is thought to be the bet- age. ter choice. Intravenous fluids are often necessary to sup- In the infant, pneumococcal pneumonia is generally of ply the needed amount of fluids. Prognosis for recovery the bronchial type. In older children, pneumococcal is excellent. pneumonia is generally of the lobar type. It is usually secondary to an upper respiratory viral infection. The most common finding in infants is a patchy infiltration NURSING PROCESS FOR THE CHILD of one or several lobes of the lung. Pleural effusion is of- WITH PNEUMONIA ten present. In the older child, the pneumonia may lo- Assessment calize in a single lobe. Immunization with the pneumo- Conduct a thorough interview with the caregiver. In ad- coccal vaccine (PCV) is currently recommended, dition to standard information, include specific data beginning at 2 months of age. such as when the symptoms were first noticed, the course H. influenzae pneumonia also occurs in infants and of the fever thus far, a description of respiratory difficul- young children. Its clinical manifestations are similar to ties, and the character of any cough. Collect data re- those of pneumococcal pneumonia, but its onset is more garding how well the child has been taking nourishment insidious, its clinical course is longer and less acute, and and fluids. Ask about nausea, vomiting, urinary and it is usually seen in the lobe of the lung. Complications bowel output, and history of exposure to other family in the infant are common—usually bacteremia, peri- members with respiratory infections. carditis, and empyema (pus in the lungs). The treatment Conduct a physical exam, including measurement of is the same. Immunization with H. influenzae type B temperature, apical pulse, respirations (rate, respiratory LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 789 Aptara

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effort, retractions [costal, intercostal, sternal, suprasternal, Implementation substernal], and flaring of nares) (see Chapter 28). Also Maintaining Airway Clearance note breath and lung sounds (crackles, wheezing), cough A humidified atmosphere is provided with an ice-cooled (dry, productive, hacking), irritability, restlessness, con- mist tent or cool vaporizer. The moisturized air helps fusion, skin color (pallor, cyanosis), circumoral (around thin the mucus in the respiratory tract to ease respira- the mouth) cyanosis, cyanotic nail beds, skin turgor, an- tions. Suction or clear secretions as needed to keep the terior fontanelle (depressed or bulging), nasal passage airway open. Position the child to provide maximum [AU3] congestion (color, consistency), mucous membranes ventilation, and change positions at least every 2 hours. (mouth dry, lips dry or cracked), and eyes (bright, glassy, Use pillows and padding to maintain the child’s position. sunken, moist, crusted). If the child is old enough to Observe frequently for slumping, which causes crowding communicate verbally, ask questions to determine how of the diaphragm. Avoid use of constricting clothes and the child feels. bedding. Stuffed toys are not recommended in mist tents because they become saturated and provide an environ- Selected Nursing Diagnoses ment in which organisms flourish. ■ Ineffective Airway Clearance related to obstruction Monitoring Respiratory Function associated with edema, mucous secretions, nasal and chest congestion Be continuously alert for warning signs of airway ob- ■ Impaired Gas Exchange related to inflammatory struction. Monitor the child at least every hour; uncover process the child’s chest and observe the child’s breathing efforts. ■ Risk for Deficient Fluid Volume related to respiratory Observe for tachypnea (rapid respirations), and note the fluid loss, fever, and difficulty swallowing amount of chest movement, shallow breathing, and re- ■ Hyperthermia related to infection process tractions. Listen with a stethoscope for breath sounds, ■ Risk for Further Infection related to location and particularly noting the amount of stridor, which indi- anatomical structure of the eustachian tubes cates difficult breathing. Oxygen saturation levels are ■ Activity Intolerance related to inadequate gas monitored using oximetry. Increasing hoarseness should exchange be reported. In addition, observe for pallor, listlessness, ■ Anxiety related to dyspnea, invasive procedures, and circumoral cyanosis, cyanotic nail beds, and restlessness; separation from caregiver these are indications of impaired oxygenation and ■ Compromised Family Coping related to child’s respi- should be reported at once. Cool, high humidity pro- ratory symptoms and child’s illness vides relief. Oxygen may be administered by hood, mist ■ Deficient Knowledge of the caregiver related to tent, or nasal cannula if the practitioner orders. child’s condition and home care Promoting Adequate Fluid Intake It is important to clear the nasal passages immediately Outcome Identification and Planning before feeding. For the infant, use a bulb syringe. Ad- The major goals for the child with pneumonia are main- minister normal saline nose drops to thin secretions taining respiratory function, preventing fluid deficit, about 10 to 15 minutes before feedings and at bedtime. maintaining body temperature, preventing otitis media, Feed the child slowly, allowing frequent stops with suc- conserving energy, and relieving anxiety. Goals for the tioning during feeding, as needed. Avoid overtiring the family include relieving anxiety and improving caregiver infant or child during feeding. knowledge. Adequate hydration helps reduce thick mucus. Main- The need for immediate intubation is always a possi- taining adequate fluid intake may be a problem for chil- bility; thus, vigilance is essential. The child’s energy must dren of any age because the child may be too ill to want be conserved to reduce oxygen requirements. The child to eat. Offer warm, clear fluids to encourage oral intake. may need to be placed on infection control precautions, Between meals, offer juices and water appropriate for according to the policy of the health care facility, to pre- the infant or child’s age. For infants, use a relatively vent nosocomial spread of infection. Many children with small-holed nipple so he or she does not choke, but does a respiratory condition need to be placed in a croupette not work too hard. Maintain accurate intake and output or mist tent, making additional nursing interventions measurements. Observe carefully for aspiration, espe- necessary. If IV fluids are ordered, interventions that pro- cially in severe respiratory distress. The child may need mote tissue and skin integrity are needed. To ensure that to be kept NPO to prevent this threat. Parenteral fluids the child does not interfere with the IV infusion site, it may be administered to replace those lost through respi- may be necessary to prepare restraints. Intravenous ad- ratory loss, fever, and anorexia. Follow all safety meas- ministration and the use of restraints are discussed in ures for administration of parenteral fluids. Observe pa- Chapter 30 (see Nursing Care Plan 36-1: The Child With tency, placement, site integrity, and flow rate, at least Pneumonia). hourly. Fluid needs are determined by the amount LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 790 Aptara

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Nursing Care Plan 36-1

THE CHILD WITH PNEUMONIA

CASE SCENARIO: CW, a 6-month-old child with pneumonia, has been brought to the hospital from the doctor’s office by his mother. He has a copious amount of thick nasal discharge and has rapid, shallow respirations with substernal and intercostal retractions. His temperature is 101.5F (39.1C). His young mother appears very anxious.

NURSING DIAGNOSIS Ineffective Airway Clearance related to infectious process GOAL: The child’s respiratory function will improve and airway will be patent. EXPECTED OUTCOMES: • The child no longer uses respiratory accessory muscles to aid in breathing. • The child’s breath sounds are clear and respirations are regular. • Mucous secretions become thin and scant; nasal passages are clear. Nursing Interventions Rationale

Provide moist atmosphere by placing him in ice- Moisture helps liquefy and thin secretions for easier cooled mist tent. respirations. Keep nasal passages clear, using bulb syringe. Open passages increase air flow. Monitor respiratory function by observing for Changes in the child’s breathing may be early indica- retractions, respiratory rate, and listening to breath tors of respiratory distress. sounds at least every 4 hours. Monitor more frequently if tachypnea or deep retractions are noted. Monitor child’s bedding and clothing every 4 hours. Clothing and bedding can become very wet from mist. Dry clothing and bedding help to prevent chilling.

NURSING DIAGNOSIS Imbalanced Nutrition: Less Than Body Requirements related to inability to suck, drink, or swallow because of congested nasal passages or fatigue from difficulty breathing GOAL: The child will have adequate food and fluid intake to maintain normal growth and development. EXPECTED OUTCOMES: • The child has an adequate caloric intake as evidenced by appropriate weight gain of 1 oz or more a day. • The child is able to suck, drink, and swallow easily without tiring. • Skin turgor returns to normal. Nursing Interventions Rationale

Clear nasal passages immediately before feeding. Infants are obligatory nasal breathers. Clearing eases Teach family caregiver to use bulb syringe. child’s breathing to permit adequate feeding. Family caregiver can use this technique at home, as needed. Administer normal saline nose drops before feedings Normal saline nose drops help thin mucous and at bedtime. secretions. Weigh infant daily in morning before first feeding. Child will maintain appropriate weight gain.

NURSING DIAGNOSIS Risk for Further Infection (otitis media) related to current respiratory infection and the size and location of child’s eustachian tube GOAL: The child will remain free from further infection and complications of otitis media. EXPECTED OUTCOMES: • The child shows no signs of ear pain, such as irritability, shaking head, pulling on ears. LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 791 Aptara

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Nursing Care Plan 36-1 (continued)

THE CHILD WITH PNEUMONIA

Nursing Interventions Rationale

Change child’s position, turning from side to side Turning child prevents mucus from pooling in the every hour. eusctachian tubes. Feed child in upright position. Upright position improves drainage and helps open nasal passages. Observe for irritability, shaking of head, or pulling Early recognition of signs of otitis media promotes at ears. early diagnosis and treatment.

NURSING DIAGNOSIS Compromised Family Coping related to child’s illness GOAL: The caregiver’s anxiety will be reduced. EXPECTED OUTCOMES: • The family caregivers verbalize understanding of the child’s condition and treatments. • The family caregivers reflect confidence in the staff evidenced by cooperation and appropriate questions. Nursing Interventions Rationale

Actively listen to caregivers’ concern. Family members gain confidence when they feel their concerns are being heard. Provide reassurance and explain what you are doing Understanding the disease and treatment methods and why you are doing it when working with the helps family to feel that the child’s illness is under child. control. Involve caregivers in caring for child. Teach Family caregivers feel valued and benefit from techniques of care that can be used at home. nursing care tips that they can use at home.

needed to maintain body weight with sufficient amounts Preventing Additional Infections added to replace the additional losses. Monitor daily Turn the child from side to side every hour so that mu- weights and accurately record intake and output. Moni- cus is less likely to drain into the eustachian tubes, tor serum electrolyte levels to ensure they are within nor- thereby reducing the risk for development of otitis me- mal limits. At least once per shift, observe and record dia. An infant seat may help facilitate breathing and skin turgor and the condition of mucous membranes. prevent the complication of otitis media in the Observe the child for dehydration; skin turgor, anterior younger child. Observe the child for irritability, shak- fontanelle (in infants), and urine output are good indica- ing of the head, pulling at the ears, or complaints of tors of dehydration. For the infant, maintain diaper ear pain. Do not give the infant a bottle while he or counts and weigh diapers to determine the amount of she is lying in bed. The best position for feeding is up- urine output (1 mL urine weighs 1 g). right to avoid excessive drainage into the eustachian tubes. Maintaining Body Temperature Monitor the child’s temperature frequently, at least every Reducing the Child’s Anxiety 2 hours if it is higher than 101.3F (38.6C). If the child When frightened or upset and crying, the child with a has a fever, remove excess clothing and covering. An- respiratory condition may hyperventilate, which causes tipyretic medications may be ordered. additional respiratory distress. For this reason, maintain a calm, soothing manner while caring for the child. Promoting Energy Conservation When possible, the child should be cared for by a con- During an acute stage, allow the child to rest as much as stant caregiver with whom a trusting relationship has possible. Plan work so that rest and sleep are interrupted been achieved. Offering support to the child during in- no more than necessary. vasive procedures, such as when an IV is being started, LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 792 Aptara

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will help decrease the child’s anxiety. The family can pro- vide the child with a favorite blanket or toy. The family Family Teaching Tips caregiver is encouraged to stay with the child if possible RESPIRATORY INFECTIONS to provide reassurance and avoid separation anxiety in the child. Plan care to minimize interrupting the child’s ■ Clear nasal passages with a bulb syringe for the much-needed rest. Give the child age-appropriate expla- infant. nations of treatment and procedures. ■ Feed the child slowly, allow the infant to breast- As the child’s condition improves, provide age-appro- feed without tiring. priate diversional activities to help relieve anxiety and ■ Frequently burp the infant to expel swallowed air. boredom. Make extra efforts to relieve the child’s feel- ■ Offer child extra fluids. ings of loneliness, especially when infection control pre- ■ Leave the child in mist tent except for feeding and cautions are being used. bathing (unless otherwise indicated). ■ Soothe and comfort child in mist or croup tent. Promoting Family Coping ■ Follow respiratory infection control precautions Watching a child with severe respiratory symptoms is and good hand-washing techniques. frightening for the parent or family caregiver. Family ■ Discourage persons with infections from visiting caregivers need teaching and reassurance. The parent or child. caregiver may feel helpless, and these feelings of anxiety ■ Use a humidifier at home after discharge. and helplessness may be exhibited in a variety of ways. ■ Clean humidifier properly and frequently. To alleviate these feelings, encourage the caregiver to dis- cuss them. Using easily understood terminology, explain equipment, procedures, treatments, the illness, and the prognosis to the caregiver. Include the caregiver in the ■ The infant no longer uses respiratory accessory mus- child’s care as much as possible and encourage him or cles to aid in breathing. her to soothe and comfort the child. Actively listen to ■ The child’s oxygen saturation levels are within estab- caregivers and use communication skills to respond to lished limits. their worries. Goal: The child’s fluid intake will be adequate for age and weight. Providing Family Teaching Expected Outcomes: The child Provide the caregiver with thorough explanations of the ■ condition’s signs and symptoms. Teach the use of cool exhibits good skin turgor and moist, pink mucous humidifiers or vaporizers, including cleaning methods membranes. ■ and safety measures to avoid burns when using a steam has urine output of 1 to 3 mL/kg/hr. vaporizer. Explain the effects, administration, dosage, Goal: The child will maintain a temperature within and side effects of medications. To be certain the infor- normal limits. mation was understood, have the parent relate specific Expected Outcome: facts to you. Write the information down in a simple ■ The child’s temperature is 98.6F to 100F way so that it can be clearly understood, and determine (37C–37.8C). that the parent can read and understand the written ma- Goal: The child’s energy will be conserved. terial. When appropriate, observe the caregiver demon- Expected Outcome: strating care of equipment and any treatments to be ■ done at home. See Family Teaching Tips: Respiratory The child has extended periods of uninterrupted rest Infections. and tolerates increased activity. Goal: The child will be free from complications of Evaluation: Goals and Expected Outcomes otitis media. Goal: The child’s airway will remain clear and patent. Expected Outcomes: The child Expected Outcomes: The child’s ■ shows no signs of ear pain such as irritability, shak- ■ airway is clear with no evidence of retractions, stri- ing of the head, pulling on the ears. dor, hoarseness, or cyanosis. ■ does not complain of ear pain. ■ mucous secretions are thin and scant. Goal: The child will experience a reduction in anxiety. Goal: The child’s respiratory function will be within Expected Outcomes: The child normal limits for age. ■ rests quietly with no evidence of hyperventilation. Expected Outcomes: ■ cooperates with care, cuddles a favorite toy for reas- ■ The child’s respiratory rate is 20 to 35 breaths per surance, smiles, and plays contentedly. minute, normal range for child’s age, regular, with Goal: The family caregiver’s anxiety will be reduced. breath sounds clear. Expected Outcomes: The family caregivers LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 793 Aptara

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■ cooperate with and participate in the child’s care. manifestations. Depletion or absence of pancreatic en- ■ appear more relaxed, verbalize his or her feelings, zymes before birth results in impaired digestive activity, and soothe the child. and the meconium becomes viscid (thick) and mucilagi- Goal: The family caregivers will verbalize an nous (sticky). The inspissated (thickened) meconium fills understanding of the child’s condition and how to the small intestine, causing complete obstruction. Clini- provide home care for the child. cal manifestations are bile-stained emesis, a distended Expected Outcomes: The family caregivers abdomen, and an absence of stool. Intestinal perforation with symptoms of shock may occur. These newborns ■ accurately describe facts about the child’s condition. taste salty when kissed because of the high sodium chlo- ■ ask appropriate questions. ride concentration in their sweat. ■ relate signs and symptoms to observe in the child. Initial symptoms of CF may occur at varying ages dur- ■ name the effects, side effects, dosage, and administra- ing infancy, childhood, or adolescence. A hard, nonpro- tion of medications. ductive chronic cough may be the first sign. Later, frequent bronchial infections occur. Development CYSTIC FIBROSIS Nutrition News of a barrel chest and Despite an excellent When first described, cystic fibrosis (CF) was called “fi- clubbing of fingers appetite in the child with brocystic disease of the pancreas.” Additional research (Fig. 36-7) indicate CF, malnutrition is has revealed that this disorder represents a major dys- chronic lack of oxy- apparent and function of all exocrine glands. The major organs affected becomes increasingly gen. The abdomen severe. are the lungs, pancreas, and liver. Because about half of all becomes distended, children with CF have pulmonary complications, this and body muscles be- disorder is discussed here with other respiratory condi- come flabby. tions. CF is hereditary and transmitted as an autosomal re- Pancreatic Involvement cessive trait. Both parents must be carriers of the gene Thick, tenacious mucus obstructs the pancreatic ducts, for CF to appear. With each pregnancy, the chance is one causing hypochylia (diminished flow of pancreatic en- in four that the child will have the disease. In the United zymes) or achylia (absence of pancreatic enzymes). This States, the incidence is about 1 in 3,300 in white children achylia or hypochylia leads to intestinal malabsorption and 1 in 16,300 in African American children. and severe malnutrition. The deficient pancreatic en- The normal gene produces a protein, cystic fibrosis zymes are lipase, trypsin, and amylase. Malabsorption of transmembrane conductance regulator, which serves as a fats causes frequent steatorrhea. Anemia or rectal pro- channel through which chloride enters and leaves cells. lapse is common if the pancreatic condition remains un- The mutated gene blocks chloride movement, which treated. The incidence of diabetes is greater in these chil- brings on the apparent signs of CF. The blocking of chlo- dren than in the general population, possibly because of ride transport results in a change in sodium transport; changes in the pancreas. The incidence of diabetes in pa- this in turn results in abnormal secretions of the exocrine tients with CF is expected to increase because of their in- (mucous-producing) glands that produce thick, tenacious creasing life expectancy. mucus rather than the thin, free-flowing secretion nor- mally produced. This abnormal mucus leads to obstruc- Pulmonary Involvement tion of the secretory ducts of the pancreas, liver, and re- The degree of lung involvement determines the progno- productive organs. Thick mucus obstructs the respiratory sis for survival. The severity of pulmonary involvement passages, causing trapped air and over inflation of the differs in individual children, with a few showing only lungs. In addition, the sweat and salivary glands excrete minor involvement. Now more than half of children excessive electrolytes, specifically sodium and chloride. with CF are expected to live beyond the age of 18 years, with increasing numbers living into adulthood. Clinical Manifestations Respiratory complications pose the greatest threat to Meconium ileus is the presenting symptom of CF in 5% children with CF. Abnormal amounts of thick, viscid to 10% of the newborns who later develop additional mucus clog the bronchioles and provide an ideal medium

■ Figure 36-7 Clubbing of fingers indicates chronic lack of oxygen. (A) Normal angle; (B) early clubbing—flattened angle; (C) advanced clubbing—the nail is rounded over the end of the finger. ABCNormal Early clubbing Advanced clubbing LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 794 Aptara

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for bacterial growth. Staphylococcus aureus coagulase tion does occur (meconium ileus equivalent), the pre- can be cultured from the nasopharynx and sputum of ferred management includes hyperosmolar enemas and most patients. Pseudomonas aeruginosa and H. influen- an increase in fluids, dietary fiber, oral mucolytics, lactu- zae also are found frequently. However, the basic infec- lose, and mineral oil. tion appears most often to be caused by S. aureus. The overall treat- Numerous complications arise from severe respiratory ment goals are to im- Good news!! infections. Atelectasis and small lung abscesses are com- prove the child’s With improved treatment, mon early complications. Bronchiectasis and emphy- quality of life and to it is not unusual for a child with CF to grow sema may develop with pulmonary fibrosis and pneu- provide for long- into adulthood. monitis; this eventually leads to severe ventilatory term survival. A insufficiency. In advanced disease, pneumothorax, right health care team is ventricular hypertrophy, and cor pulmonale are common needed, including a complications. Cor pulmonale is a common cause of primary care provi- death. der, a nurse, a respira- tory therapist, a dietitian, and a social worker, to work to- Other Organ Involvement gether with the child and family. Treatment centers with a The tears, saliva, and sweat of children with CF contain staff of specialists are becoming more common, particu- abnormally high concentrations of electrolytes, and larly in larger medical centers. most such children have enlarged submaxillary salivary glands. In hot weather, the loss of sodium chloride and Dietary Treatment fluid through sweating produces frequent heat prostra- Commercially prepared pancreatic enzymes given during tion. Additional fluid and salt should be given in the diet meals or with snacks aid digestion and absorption of fat as a preventive measure. In addition, males with CF who and protein. Because pancreatic enzymes are inactivated reach adulthood will most likely be sterile because of the in the acidic environment of the stomach, microencapsu- blockage or absence of the vas deferens or other ducts. lated capsules are used to deliver the enzymes to the duo- Females often have thick cervical secretions that prohibit denum, where they are activated. These enzymes come in the passage of sperm. capsules that can be swallowed or opened and sprinkled on the child’s food. A powdered preparation is used for Diagnosis infants. Diagnosis is based on family history, elevated sodium The child’s diet should be high in carbohydrates and chloride levels in the sweat, analysis of duodenal secre- protein, with no restriction of fats. The child may need tions (via a nasogastric tube) for trypsin content, a his- 1.5 to 2 times the normal caloric intake to promote tory of failure to thrive, chronic or recurrent respiratory growth. These children have large appetites unless they infections, and radiologic findings of hyperinflation and are acutely ill. However, even with their large appetites bronchial wall thickening. In the event of a positive they can receive little nourishment without a pancreatic sodium chloride sweat test, at least one other criterion supplement. With proper diet and enzyme supplements, must be met to make a conclusive diagnosis. these children show evidence of improved nutrition, and The principal diagnostic test to confirm CF is a sweat their stools become relatively normal. Enteric-coated chloride test using the pilocarpine iontophoresis method. pancreatic enzymes essentially eliminate the need for di- This method induces sweating by using a small electric etary restriction of fat. current that carries topically applied pilocarpine into a Because of the increased loss of sodium chloride, these localized area of the skin. Elevations of 60 mEq/L or children are allowed to use as much salt as they wish, more are diagnostic, with values of 50 to 60 mEq/L even though onlookers may think it is too much. During highly suspect. Although the test itself is fairly simple, hot weather, additional salt may be provided with pret- conducting the test on an infant is difficult, and false- zels, salted bread sticks, and saltine crackers. positive results do occur. Supplements of fat-soluble vitamins A, D, and E are necessary because of the poor digestion of fats. Vitamin Treatment K may be supplemented if the child has coagulation In the newborn, meconium ileus is treated with hyperos- problems or is scheduled for surgery. Water-miscible molar enemas administered gently. If this does not re- preparations can be given to provide the needed supple- solve the blockage of thick, gummy meconium, surgery ment. is necessary. During surgery, a mucolytic, such as Mu- comyst, may be used to liquefy the meconium. If this Pulmonary Treatment procedure is successful, resection may not be necessary. The treatment goal is to prevent and treat respiratory in- In the older child, treatment is aimed at correcting fections. Respiratory drainage is provided by thinning pancreatic deficiency, improving pulmonary function, the secretions and by mechanical means, such as and preventing respiratory infections. If bowel obstruc- postural drainage and clapping to loosen and drain LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 795 Aptara

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secretions from the lungs. Antibacterial drugs for the Physical activity is A little fun can be good. treatment of infection are necessary as indicated. Some an important ad- The older child with CF physicians prescribe a prophylactic antibiotic regimen junct to the child’s can learn to hang from a when the child receives the diagnosis of CF. Antibiotics well-being and is monkey bar by the may be administered orally or parenterally, even in the necessary to get rid knees, having fun and home. With home parenteral administration of antibi- of secretions. Capac- at the same time otic therapy, a central venous access device is used. Im- ity for exercise is increasing postural drainage. munization against childhood communicable diseases is soon learned, and extremely important for these chronically ill children. the child can be All immunization measures may be used and should be trusted to become self- maintained at appropriate intervals. limiting as necessary, especially if given an opportunity to Physical activity is essential because it improves mu- learn the nature of the disease. The child may find postural cous secretion and helps the child feel good. The child drainage fun when a caregiver raises the child’s feet in the can be encouraged to participate in any aerobic activity air and walks the child around “wheelbarrow” fashion. he or she enjoys. Activity along with physical therapy Providing as much normalcy as possible is always de- should be limited only by the child’s endurance. sirable. Hot-weather activity should be watched a little Inhalation therapy can be preventive or therapeutic. A more closely, with additional attention to increased salt bronchodilator drug, such as theophylline or a beta- and fluid intake during exercise. adrenergic agonist (metaproterenol, terbutaline, or al- Caring for a child with CF places great stress on a fam- buterol), may be administered either orally or through ily’s financial resources. The expense of daily medica- nebulization. Recombinant human DNA (DNase, Pul- tions, frequent clinic or office visits, and sometimes mozyme) breaks down DNA molecules in sputum, lengthy hospitalizations can be devastating to an ordi- breaking up the thick mucus in the airways. A mucolytic, nary family budget, even with medical insurance cover- such as Mucomyst, may be prescribed during acute in- age. The Cystic Fibrosis Foundation (www. cff.org), with fection. Hand-held nebulizers are easy to use and con- chapters throughout the United States, is helpful in pro- venient for the ambulatory child. viding education and services. Some assistance may be Humidifiers provide a humidified atmosphere. In sum- available through local agencies or community groups. mer, a room air conditioner can help provide comfort and controlled humidity. Chest physical therapy, a combination of postural Nursing Process for the Child drainage and chest percussion, is performed routinely at With Cystic Fibrosis least every morning and evening, even if little drainage Assessment is apparent (Fig. 36-8). Performed correctly, chest per- The collection of data on the child with CF varies, de- cussion (clapping and vibrating of the affected areas) pending on the child’s age and the circumstances of the helps to loosen and move secretions out of the lungs. admission. Conduct a complete parent interview that in- The physical therapist usually performs this procedure cludes the standard information, as well as data con- in the hospital and teaches it to the family. Chest phys- cerning respiratory infections, the child’s appetite and ical therapy, although time consuming, is part of the eating habits, stools, noticeable salty perspiration, his- ongoing, long-term treatment and should be continued tory of bowel obstruction as an infant, and family his- at home. tory for CF, if known. Also determine the caregiver’s knowledge of the condition. Home Care When collecting data about vital signs, include obser- The home care for a child with CF places a tremendous vation of respirations, such as cough, breath sounds, and burden on the family. This is not a one-time hospital barrel chest; respiratory effort, such as retractions and treatment and there is no prospect of cure to brighten the nasal flaring; clubbing of the fingers; and signs of pan- horizon. Each day, much time is spent performing treat- creatic involvement, such as failure to thrive and steat- ments. Family caregivers must learn to perform chest orrhea. Examine the skin around the rectum for irrita- physical therapy, how to operate respiratory equipment, tion and breakdown from frequent foul stools. Involve and administer IV antibiotics, when necessary. The the child in the interview process by asking age-appro- child’s diet must be planned with additional enzymes priate questions, and determine the child’s perception of regulated according to need. Great care is needed to pre- the disease and this current illness. vent exposure to infections. Family caregivers must guard against overprotection Selected Nursing Diagnoses and against undue limitation of their child’s physical ac- ■ Ineffective Airway Clearance related to thick, tena- tivity. Somehow, caregivers must preserve a good family cious mucus production relationship, also giving time and attention to other ■ Ineffective Breathing Pattern related to tracheo- members of the family. bronchial obstruction LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 796 Aptara

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POSITION #1, for infants UPPER LOBES, Apical segments

POSITION #1 POSITION #2 UPPER LOBES, Apical segments UPPER LOBES, Posterior segments

POSITION #4 LINGULA

POSITION #3 UPPER LOBES, Anterior segments

POSITION #5 POSITION #6 MIDDLE LOBE LOWER LOBES, Anterior basal segments

■ Figure 36-8 Positions for postural drainage. LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 797 Aptara

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POSITION #7 LOWER LOBES, Posterior basal segments

POSITION #8 & 9 LOWER LOBES, Lateral basal segments POSITION #10 LOWER LOBES, Superior segments

■ Figure 36-8 Continued

■ Risk for Infection related to bacterial growth medi- Implementation um provided by pulmonary mucus and impaired Improving Airway Clearance body defenses Mucus obstructs the airways and diminishes gas ex- ■ Imbalanced Nutrition: Less Than Body Requirements change. Monitor the child for signs of respiratory dis- related to impaired absorption of nutrients tress, while observing for dyspnea, tachypnea, labored ■ Anxiety related to hospitalization respirations with or without activity, retractions, nasal ■ Compromised Family Coping related to child’s flaring, and color of nail beds. Perform aerosol treat- chronic illness and its demands on caregivers ments. Teach the child to cough effectively. Examine and ■ Deficient Knowledge of the caregiver related to ill- document the mucus produced, noting the color, consis- ness, treatment, and home care tency, and odor. Send cultures to the laboratory, as ap- propriate. Increase fluid intake to help thin mucous se- Outcome Identification and Planning cretions. Encourage the child to drink extra fluids and As already stated, much depends on the reason for the ask the child (or the caregiver if the child is too young) specific admission and other factors discussed in Nursing what favorite drinks might be appealing. Intravenous Diagnoses. The child’s age and ability for self-expression fluids may be necessary. Provide humidified air, either in affect any goal setting the child can do. The major goals the form of a cool mist humidifier or mist tent, as pre- for the child include relieving immediate respiratory dis- scribed. tress, maintaining adequate oxygenation, remaining free from infection, improving nutritional status, and reliev- Improving Breathing ing anxiety. The caregivers’ primary goal may include re- Maintain the child in a semi-Fowler’s position, with the lieving problems related to this admission. However, upper half of the body elevated about 30 degrees, or other goals may include concerns about stress on the high Fowler’s position, with the upper half of the body family related to the illness, as well as a need for addi- elevated about 90 degrees, to promote maximal lung ex- tional information about the disease, treatment, and pre- pansion. Pulse oximetry may be used. Maintain oxygen vention of complications. saturation higher than 90%. Administer oxygen as LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 798 Aptara

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ordered if the oxygen saturation falls below this level Reducing the Child’s Anxiety for an extended period. Administer mouth care every 2 Provide age-appropriate activities to help alleviate anxi- to 4 hours, especially when oxygen is administered. Per- ety and the boredom that can result from hospitalization. form chest physical therapy every 2 to 4 hours, as or- Choose activities such as reading or arts and crafts ac- dered. If respiratory therapy technicians or physical cording to age. Schoolwork may help ease some anxiety. therapists do these treatments, observe the child after Some older children may enjoy a video game, if available, the treatment to determine effectiveness and if more fre- but watch the child for overexcitement. Encourage the quent treatments may be needed. Supervise the child family caregiver to stay with the child to help diminish who can self-administer nebulizer treatments to ensure some of the child’s anxiety. Allow the child to have fa- correct use. miliar toys or mementos from home. Stay with the child Conserve the child’s energy. Plan nursing and thera- during acute episodes of coughing and dyspnea to reduce peutic activities so that maximal rest time is provided for anxiety. Give the child age-appropriate information the child. Note dyspnea and respiratory distress in rela- about CF. Quiz the child in a relaxed, friendly manner to tion to any activities. Plan quiet diversional activities as help determine what the child knows and what teaching the child’s physical condition warrants. Help the child may be needed. Learning about CF can be turned into a and family to understand that activity is excellent for the game for some children, making it much more enjoyable. child not in an acute situation. Teach them that exercise helps loosen the thick mucus and also improves the Providing Family Support child’s self-image. The family with a child who has CF is faced with a long- term illness and may have already seen deterioration in Preventing Infection the child’s health. Give the family and the child oppor- The child with CF has low resistance, especially to res- tunities to voice fears and anxieties. Respond with ac- piratory infections. For this reason, take care to protect tive-listening techniques to help authenticate their feel- the child from any exposure to infectious organisms. ings. Provide emotional support throughout the entire Good hand-washing techniques should be practiced by hospital stay. Demonstrate an interest and willingness to all; teach the child and family the importance of this first talk to the family; do not make family members feel as line of defense. Practice and teach other good hygiene though they are intruding on time needed to do other habits. Carefully follow medical asepsis when caring for things. As the nurse, you are the person who can best the child and the equipment. Monitor vital signs every provide overall support. 4 hours for any indication of an infectious process. Re- strict people with an infection, such as staff, family Providing Family Teaching members, other patients, and visitors, from contact with Evaluate the family’s knowledge about CF to determine the child. Advise the family to keep the child’s immu- their teaching needs. The family may need to have all the nizations up to date. Administer antibiotics as pre- information repeated or may need clarification in just a scribed, and teach the child or caregiver home adminis- few areas. Provide information for resources such as the tration, as needed. Also, teach the family the signs and Cystic Fibrosis Foundation, the American Lung Associa- symptoms of an impending infection so they can begin tion (www.lungusa.org), and other local organizations. prophylactic measures at once. The family may have questions about genetic counseling and may need referrals for counseling. Maintaining Adequate Nutrition Adequate nutrition helps the child resist infections. Evaluation: Goals and Expected Outcomes Greatly increase the child’s caloric intake to compensate Goal: The child’s airway will be clear. for impaired absorption of nutrients and to provide ad- Expected Outcomes: The child equate growth and development. In addition to in- ■ effectively clears mucus from the airway and the creased caloric intake at meals, provide the child with airway remains patent. high-calorie, high-protein snacks, such as peanut butter ■ cooperates with chest physical therapy. and cheese. Low-fat products can be selected, if desired. Goal: The child will exhibit adequate respiratory function. Administer pancreatic enzymes with all meals and Expected Outcomes: The child snacks. In addition, multiple vitamins and iron may be ■ rests quietly with no dyspnea; the respiratory rate is prescribed. Reinforce the need for these supplements to even and appropriate for age. both the child and the family. The child also may require ■ maintains oxygen saturation above 90%. additional salt in the diet. Encourage the child to eat salty snacks. If the child has bouts of diarrhea or consti- Goal: The child will remain free of signs and symptoms pation, the dosage of enzymes may need to be adjusted. of infection. Report any change in bowel movements. Weigh and Expected Outcomes: measure the child. Plot growth on a chart so that ■ The child’s vital signs are within normal limits for age. progress can easily be visualized. ■ The child and family follow infection-control practices. LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 799 Aptara

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Goal: The child’s nutritional intake will be adequate to Tuberculosis is caused by Mycobacterium tuberculosis, compensate for decreased absorption of nutrients and a bacillus spread by droplets of infected mucus that be- to provide for adequate growth and development. come airborne when the infected person sneezes, Expected Outcomes: The child coughs, or laughs. The bacilli, when airborne, are in- ■ demonstrates weight gain appropriate for age. haled into the respiratory tract of the unsuspecting person and become implanted in lung tissue. This ■ exhibits normal growth as indicated by growth chart. process is the beginning of the formation of a primary Goal: The child’s anxiety will subside. lesion. Expected Outcome: ■ The child engages in age-appropriate activities and Clinical Manifestations appears relaxed. Primary tuberculosis is the original infection that goes Goal: The family caregivers will verbalize feelings re- through various stages and ends with calcification. Pri- lated to the child’s chronic illness. mary lesions in children are generally unrecognized. The Expected Outcome: most common site of a primary lesion is the alveoli of the respiratory tract. Most cases arrest with the calcifi- ■ The family caregivers verbalize fears, anxieties, and cation of the primary infection. However, in children other feelings related to the child’s illness. with poor nutrition or health, the primary infection may Goal: The family caregivers will verbalize an invade other tissues of the body, including the bones, understanding of the child’s illness and treatment. joints, kidneys, lymph nodes, and meninges. This is Expected Outcomes: The family caregivers called miliary tuberculosis. In the small number of chil- ■ explain CF and describe treatments and possible dren with miliary tuberculosis, general symptoms of complications. chronic infection, such as fatigue, loss of weight, and ■ become involved in available support groups. low-grade fever, may occur accompanied by night sweats. Secondary tuberculosis is a reactivation of a healed Test Yourself primary lesion. It often occurs in adults and contributes to the exposure of children to the organism. Although ✔ What two immunizations have decreased the inci- secondary lesions are more common in adults, they may dence of bacterial pneumonia in children? occur in adolescents. Symptoms resemble those in an ✔ What major organs are affected by CF? adult, including cough with expectoration, fever, weight ✔ What is the dietary treatment for CF? loss, malaise, and night sweats. ✔ For what type of infection is the child with CF most Diagnosis susceptible? The tuberculin skin test is the primary means by which tuberculosis is detected. A skin test can be performed using a multipuncture device that deposits purified PULMONARY TUBERCULOSIS protein derivative intradermally (tine test) or by intra- Tuberculosis is present in all parts of the world and is the dermal injection of 0.1 mL of purified protein deriva- most important chronic infectious disease in terms of ill- tive. Both tests are administered on the inner aspect of ness, death, and cost (Starke, 2006). The incidence of tu- the forearm. The site is marked and read at 48 and 72 berculosis in the United States had declined steadily un- hours. Redness, swelling, induration, and itching of til about 1985. In the years since, there has been an the site indicate a positive reaction. Persons with a increase in the number of cases reported in the United positive reaction are further examined by radiographic States. Several factors contribute to this increase; one evaluation. Sputum tests of young children are rarely factor is the number of people who have human im- helpful because children do not produce a good speci- munodeficiency virus and have become infected with men. Screening by means of skin testing is recom- tuberculosis. mended for all children at 12 months, before entering school, and in adolescence. Screening is recommended annually for children in high-risk situations or com- Cultural Snapshot munities including children in whose family there is an active case; Native Americans; and children who re- In some cultures, it is common for many people to cently immigrated from Central or South America, the live together in one home or in a close living Caribbean, Africa, Asia, or the Middle East. Other arrangement. Respiratory illness is easily spread from high-risk children are those infected with human im- person to person when people live in close contact munodeficiency virus, those who are homeless or live with each other. in overcrowded conditions, and those immunosup- pressed for any reason. LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 800 Aptara

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Treatment Prevention Drug therapy for tuberculosis includes administration of Prevention requires improvements in social conditions isoniazid (INH), often in combination with rifampin. Al- such as overcrowding, poverty, and poor health care. though INH has been known to cause peripheral neuri- Also needed are health education; medical, laboratory, tis in children with poor nutrition, few problems occur and radiographic facilities for examination; and control in children whose diets are well balanced. Rifampin is of contacts and persons suspected of infection. tolerated well by children but causes body fluids such as A vaccine called bacilli Calmette-Guérin (BCG) is used urine, sweat, tears, and feces to turn orange-red. A pos- in countries with a high incidence of tuberculosis. It is sible disadvantage for adolescents is that it may perma- given to tuberculin-negative persons and is said to be ef- nently stain contact lenses. Rifamate is a combination of fective for 12 years or longer. Mass vaccination is not rifampin and INH. Other drugs that may be used are considered necessary in parts of the world where the in- ethambutol, streptomycin, and pyrazinamide. cidence of tuberculosis is low. After administration of Drug therapy is continued for 9 to 18 months. After BCG vaccine, the skin test will be positive, so screening drug therapy has begun, the child or adolescent may re- is no longer an effective tool. The use of BCG vaccine re- turn to school and normal activities unless clinical symp- mains controversial because of the effect it has on toms are evident. An annual chest radiograph is neces- screening for the disease, as well as the questionable ef- sary from that time on. fectiveness of the vaccine.

Key Points

➤ An infant or child’s respiratory system, because of hoarse. Humidified air is used to decrease the laryn- its small size and underdeveloped anatomic gospasm. A low dose of an emetic may be used to structures, is more prone to respiratory problems. reduce spasms of the larynx. Acute laryngotracheo- Smaller structures lead to a greater chance of bronchitis is often caused by the staphylococcal obstruction and respiratory distress. As the child bacterium. The child may become hoarse and have grows, the use of the thoracic muscles takes the a barking cough and elevated temperature. Breath- place of the use of the diaphragm and abdominal ing difficulty, a rapid pulse, and cyanosis may muscles for breathing. occur. Antibiotics are given and the child is placed ➤ The most common complication of acute in a croupette or mist tent with oxygen. Epiglottitis nasopharyngitis (common cold) is otitis media. is an acute inflammation of the epiglottis and is not ➤ Avoiding or removing allergens is the best way to commonly seen. prevent allergic rhinitis. Antihistamines and ➤ Bronchiolitis/RSV is caused by a viral infection. hyposensitization may be helpful for some patients. Dyspnea occurs as well as a dry and persistent ➤ The child with tonsillitis may have a fever, sore cough, extremely shallow respirations, air hunger, throat, difficulty swallowing, hypertrophied tonsils, and cyanosis. Suprasternal and subcostal retractions and erythema of the soft palate. Exudate may be are present with respirations as high as 60 to 80 visible on the tonsils. Treatment of tonsillitis breaths per minute. Diagnosis is made from clinical consists of analgesics, antipyretics, and antibiotics. findings confirmed by laboratory testing (enzyme- Surgical removal of the tonsils and adenoids may linked immunosorbent assay [ELISA]). The child is be indicated. hospitalized, placed on contact transmission ➤ The most common complication of a tonsillectomy precautions, and treated with high humidity by mist is hemorrhage or bleeding. The child must be tent, rest, and increased fluids. Ribavirin (Virazole), observed, especially in the first 24 hours, after sur- an antiviral drug, may be used. gery and in the fifth to seventh postoperative days ➤ An asthma attack can be triggered by a hypersensi- for unusual restlessness, anxiety, frequent swallow- tive response to allergens; foods such as chocolate, ing, or rapid pulse. Vomiting bright, red-flecked milk, eggs, nuts, and grains; exercise; or exposure emesis or bright red oozing or bleeding may to cold or irritants such as wood-burning stoves, indicate hemorrhage. If noted, these should be cigarette smoke, dust, and pet dander. Infections, reported immediately. stress, or anxiety can also trigger an asthma attack. ➤ Spasmodic laryngitis may be of infectious or aller- ➤ During an asthma attack, the combination of gic origin. An attack is often preceded by a runny smooth muscle spasms, which cause the lumina of nose and hoarseness. The child awakens after a few the bronchi and bronchioles to narrow; edema; and hours of sleep with a bark-like cough; respiratory increased mucus production causes respiratory difficulty; stridor; and may be anxious, restless, and obstruction. LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 801 Aptara

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➤ The goals of asthma treatment include preventing free-flowing secretions. These secretions obstruct symptoms, maintaining near-normal lung function the secretory ducts of the pancreas, liver, and repro- and activity levels, preventing recurring ductive organs. exacerbations and hospitalizations, and providing ➤ The sweat chloride test, which shows elevated the best medication treatment with the fewest sodium chloride levels in the sweat, is the principal adverse effects. Nursing care is focused on maintain- diagnostic test used to confirm CF. Family history, ing a clear airway, maintaining an adequate fluid analysis of duodenal secretions for trypsin content, intake, and relieving fatigue and anxiety. history of failure to thrive, chronic or recurrent res- ➤ Bacterial pneumonia is usually caused by pneumo- piratory infections, and radiologic findings also help coccal or H. influenzae bacterium. The onset is usu- diagnose the disorder. ally abrupt, following a mild upper respiratory ill- ➤ The most common and serious complications of CF ness. Symptoms may include a high temperature, arise from respiratory infections, which may lead to respiratory distress with air hunger, flaring of the severe respiratory concerns. nostrils, circumoral cyanosis, and chest retractions. ➤ Pancreatic enzymes given with meals and snacks are Tachycardia and tachypnea are present, with a used in the dietary treatment of children with CF. pulse rate as high as 140 to 180 beats per minute The child’s diet is high in protein and carbohydrates, and respirations as high as 80 breaths per minute. and salt in large amounts is allowed. The use of Anti-infectives, such as penicillin or ampicillin, have chest physiotherapy, antibiotics, and inhalation proved to be the most effective in the treatment of therapy help in the prevention and treatment of pneumonia. If the child has a penicillin allergy, respiratory infections. cephalosporin anti-infectives are also used. Nursing ➤ Tuberculosis can be detected by doing a tuberculin care is focused on maintaining respiratory function, skin test using purified protein derivative. When a preventing fluid deficit, maintaining body tempera- person has a positive reaction to the skin test, addi- ture, preventing otitis media, conserving energy, tional evaluation using radiography is done to con- and relieving anxiety. firm the disease. INH and Rifampin are used to ➤ CF causes the exocrine (mucous-producing) glands treat tuberculosis and are given for 9 to 18 to produce thick, tenacious mucus, rather than thin, months.

INTERNET RESOURCES American Lung Association Cystic Fibrosis Foundation www.lungusa.org www.cff.org American Academy of Allergy Asthma and National Heart, Lung, and Blood Institute Immunology www.nhlbi.nih.gov www.aaaai.org Asthma and Allergy RSV www.aafa.org www.marchofdimes.com/pnhec/298_9546.asp LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 802 Aptara

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a. “It is good to know that my other children won’t Workbook have the disease.” b. “I will be sure to give my child the medication ■ NCLEX-STYLE REVIEW QUESTIONS every time she eats.” c. “It is important to let my child play with the 1. The nurse is doing teaching with the caregivers of a other kids when she is at school.” child who has had a tonsillectomy the previous day d. “When she exercises, I will feed her a salty and is being discharged. The nurse would reinforce snack.” that which of the following should be reported immediately to the child’s physician? 6. The nurse is completing the intake and output a. The child complains of a sore throat on the third record for a toddler who has a respiratory infection. postoperative day. The dry weight of the child’s diaper is 38 g. The b. The child refuses to leave the ice collar on for child has had the following intake and output more than 10 minutes. during the shift: c. The child vomits dark, old blood within 4 hours Intake: 3 oz of apple juice 1 after being discharged. ⁄2 serving of pancakes d. The child has frequent swallowing around the 5 oz of milk sixth day after surgery. 4 saltine crackers 1 ⁄4 cup of chicken soup 2. A toddler with a diagnosis of a respiratory 2 oz of gelatin disorder has a fever and decreased urinary output. 130 cc of IV fluid When planning care for this child, which of the Output: Diaper with urine weighing 87 f following goals would be most appropriate for this Diaper with stool only weighing 124 f toddler? Diaper with urine weighing 138 f a. The child’s anxiety will be reduced. Diaper with urine weighing 146 f b. The child’s fluid intake will be increased. Diaper with urine weighing 95 f c. The child’s caregivers will talk about their a. How many milliliters should the nurse document concerns. as the child’s total intake? d. The child’s caloric intake will be adequate for b. How many milliliters should the nurse document age. as the child’s urinary output? 3. The nurse is teaching a group of caregivers of children who have asthma. The caregivers make the ■ STUDY ACTIVITIES following statements. Which of these statements in- dicates a need for additional teaching? 1. Draw a diagram to explain the heredity pattern of a. “We need to identify the things that trigger our cystic fibrosis. child’s attacks.” 2. Research your community to find sources of help b. “I always have him use his bronchodilator before for families with children who have cystic fibrosis. he uses his steroid inhaler.” What support groups and organizations are avail- c. “We will be sure our child does not exercise to able that you might recommend to families of prevent attacks.” children with cystic fibrosis? Discuss with your d. “She drinks lots of water, which I know helps to peers what you found and make a list of resources thin her secretions.” to share. 4. A child with cystic fibrosis will have which of the following interventions included in the child’s plan 3. Go to the following Web site: www.lungusa.org. Find of care? the section on Asthma and on the drop down menu, click on “Asthma & Children.” Click on “Early a. Maintain a flat lying position when in bed. Warning Signals: Asthma Always Gives a Sign.” b. Provide low protein snacks between meals. c. Perform postural drainage in the morning and a. List six areas covered on this site that you could evening. share with a family of a child with asthma. d. Teach infection control procedures when b. What five suggestions are given in the area cover- hospitalized. ing “What to Listen For?” c. Read the section on “How to Listen.” 5. After discussing the disease with the caregiver of a d. Describe how you listen to the breath sounds in a child with cystic fibrosis, the caregiver makes the child with asthma. following statements. Which of these statements e. What are five emergency signs that require imme- indicates a need for additional teaching? diate treatment? LWBK284-4156G-c36_p775-803.qxd 6/28/09 9:10 PM Page 803 Aptara

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■ CRITICAL THINKING: Rachel, and a diagnosis of an acute asthma attack is WHAT WOULD YOU DO? made. 1. Sandy calls the 24-hour pediatric health line at a. What other findings might have been noted dur- 10:30 p.m. about her 2.5-year-old child Jared. Jared ing a physical exam of Rachel? had gone to bed at his usual bedtime of 8:00 p.m. b. What will most likely be done to treat Rachel’s after an uneventful evening. He had awakened with current condition? a bark-like cough, respiratory difficulty, and a high- c. What medications might have been given? pitched harsh sound on inspiration. d. What would you teach Rachel’s parents about prevention of additional attacks? a. What questions would you ask this mother to further clarify Jared’s situation? 3. Dosage calculation: A toddler with a diagnosis of b. What would you suggest Sandy should do to de- cystic fibrosis is being treated with the bronchodila- crease Jared’s symptoms? tor Theophylline. The child weighs 32 lb. The usual c. What would you tell Sandy to watch for that dosage of this medication is 4 mg/kg/dose every might indicate Jared needs emergency attention? 6 hours. Answer the following: 2. Rachel, a 6-year-old girl, is brought to the clinic a. How many kilograms does the child’s weigh? with a dry hacking cough, wheezing, and difficulty b. How many milligrams per dose will be given? breathing. Rachel is coughing up thick mucus. Her c. How many doses will the child receive in a day? parents are with her and are extremely anxious d. How much Theophylline will be given in a about Rachel’s condition. The pediatrician examines 24-hour period?